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Blue Toe Syndrome as an Early Sign of Disseminated Intravascular Coagulation

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Kwang-Hyun Choi
Kwang-Hyun Choi
Kwang-Hyun Choi
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Jisook Yoo
Jisook Yoo
Jisook Yoo
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Joon Won Huh
Joon Won Huh
Joon Won Huh
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Young-In Jeong
Young-In Jeong
Young-In Jeong
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Letter to the Editor
400 Ann Dermatol
Received April 21, 2015, Revised June 12, 2015, Accepted for publication
J
une 17, 2015
Corresponding author: Hyang-Joon Park, Department of Dermatology, VHS
Medical Center, 53, Jinhwangdo-ro 61-gil, Gangdong-gu, Seoul 05368,
Korea. Tel: 82-2-2225-1388, Fax: 82-2-471-5514, E-mail: choikohy@
gmail.com
T
his is an Open Access article distributed under the terms of the Creative
Commons Attribution Non-Commercial License (http://creativecommons.
org/licenses/by-nc/4.0) which permits unrestricted non-commercial use,
distribution, and reproduction in any medium, provided the original work
is properly cited.
Copyright © The Korean Dermatological Association and The Korean
Society for Investigative Dermatology
Fig. 1. Blue to purple discoloration with petechiae on the right
foot.
http://dx.doi.org/10.5021/ad.2016.28.3.400
Blue Toe Syndrome as an Early Sign of Disseminated
Intravascular Coagulation
Kwang-Hyun Choi, Jisook Yoo, Joon Won Huh, Young-In Jeong, Min Soo Kim, Mihn Sook Jue,
Hyang-Joon Park
Department of Dermatology, VHS Medical Center, Seoul, Korea
Dear Editor:
Blue toe syndrome (BTS) is often described as painful dig-
its with blue or purple discoloration without direct trau-
ma
1
. Also it can lead to the amputation of toes and feet
and be life threatening. Atheromatous embolism caused
by vascular wall injuries from invasive percutaneous pro-
cedures or from anticoagulant or fibrinolytic therapy is re-
ported as a common cause of BTS
2
. However, other caus-
es of decreased blood flow are thrombosis, vasoconstrictive
disorders, infectious and noninfectious inflammation, and
other vascular obstruction
2
. The conditions which lead to
thrombotic state such as disseminated intravascular coagu-
lation (DIC) can also give rise to BTS. Herein, we report a
rare case of BTS that occurred as an early sign of DIC.
In our institute, a 69-year-old male complained of non-pal-
pable bluish discoloration on both feet after he was admit-
ted to the ICU ward due to pneumonia (Fig. 1). The phys-
ical examination demonstrates symmetric color change
with petechiae that had lasted 1 month. The toes felt cold,
and the sensation of toes was uncheckable because of his
semi-coma status. Also the patient has been treated for
pneumonia with history of diabetes mellitus, hyper-
tension, and cerebral infarct. On histological examination
from his foot, ischemic necrosis of epidermis and tons of
red blood cell extravasation were found (Fig. 2A, B). Also,
there were eosinophilic fibrinoid thrombi in the me-
dium-sized vessels and leukocytoclasis (Fig. 2C). The labo-
ratory results were as follows: white blood cell 28,470/mm
3
,
hemoglobin 9.4 g/dl, platelet 37,000/mm
3
, prothrombin
time/activated partial thromboplastin time 18.4/91.7 s, fi-
brinogen 71 mg/dl, D-dimer 3.75 mg/L. Hence, we could
confirm that the causative disease might be DIC. After
then, we obtained the result of multi drug resistant acine-
tobacter baumannii bacteremia from the blood culture.
Gram stain and bacterial culture of the skin tissue were
not conducted. We concluded that DIC resulted from se-
vere infectious bacteremia. Henceforward, the patient was
treated with vancomycin and conservative care for DIC.
However, the patient died after 1 month. The possibility
of purpura fulminans was ruled out because the patient’s
lesion was limited to the toes.
Some conditions that might lead to the slow blood flow or
vascular damage that causes BTS are: 1) decreased arterial
Letter to the Editor
Vol. 28, No. 3, 2016
401
Fig. 2. (A) Scanning view (H&E, ×40). (B) Ischemic necrosis of epidermis, and red blood cell extravasation (H&E, ×200). (C) Eosinophilic
fibrinoid thrombi in medium-sized vessels (arrow) and leukocytoslasis (H&E, ×400).
perfusion, 2) impaired venous outflow, and 3) abnormal
circulating blood
2,3
. Our case corresponds with decreased
arterial flow, by thrombosis, not by embolism
2
. Histologically
intravascular fibrin thrombi proved this thrombosis in our
case. Besides, this hypercoagulable states can developed
diverse cutaneous findings other than BTS
2
. But if the pa-
tient’s underlying disease is unclear, we should commit
several kinds of work-up such as complete blood count,
blood chemistry, urinalysis, culture, antibody, X-ray as
well as computerized tomography angio
2
.
DIC is a process which describes widespread abnormal
activation of the clotting pathway and generation of excess
thrombin
2,4
. It results in intravascular fibrin formation and
thrombotic occlusion of small and larger vessels. Although
DIC has to be managed in internal medicine, there are
some needs for dermatologists to know it. Because most
initial signs of DIC begin with cutaneous findings like BTS,
petechiae, purpura fulminans, peripheral gangrene
5
. In con-
clusion, we report an instructive case of BTS as an early
sign of DIC.
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... Another unique finding in this case, was the patient's foot pain and ischemic skin changes noted on the patient's lower extremities (Fig. 1). BTS is caused by conditions that compromise arterial blood circulation and/or venous outflow, causing the blue or violaceous discoloration that occurs in the toes [22][23][24]. BTS is often attributed to atheroembolism [22,23]. BTS as the initial presentation of DIC has been reported in an isolated case [22]. ...
... BTS is caused by conditions that compromise arterial blood circulation and/or venous outflow, causing the blue or violaceous discoloration that occurs in the toes [22][23][24]. BTS is often attributed to atheroembolism [22,23]. BTS as the initial presentation of DIC has been reported in an isolated case [22]. ...
... BTS is often attributed to atheroembolism [22,23]. BTS as the initial presentation of DIC has been reported in an isolated case [22]. In summary, our case highlights uncommon arterio-venous thromboses due to non-promyelocytic AML. ...
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Cutaneous changes in peripheral arterial vascular disease
  • V Chadachan
  • Sm Dean
  • Rt Eberhardt
  • La Goldsmith
  • Si Katz
Chadachan V, Dean SM, Eberhardt RT. Cutaneous changes in peripheral arterial vascular disease. In: Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K, editors.
Cutaneous changes in peripheral arterial vascular disease
  • V Chadachan
  • S M Dean
  • R T Eberhardt
  • L A Goldsmith
  • S I Katz
  • B A Gilchrest
  • A S Paller
  • D J Leffell
  • K Wolff
Chadachan V, Dean SM, Eberhardt RT. Cutaneous changes in peripheral arterial vascular disease. In: Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K, editors.